Healthcare Provider Details

I. General information

NPI: 1669605374
Provider Name (Legal Business Name): MAYRA PEREZ LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2009
Last Update Date: 11/14/2021
Certification Date: 11/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 RANCHO LOS GUILICOS RD
SANTA ROSA CA
95409-6519
US

IV. Provider business mailing address

7425 RANCHO LOS GUILICOS RD
SANTA ROSA CA
95409-6519
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6318
  • Fax:
Mailing address:
  • Phone: 707-565-6319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRI-P0908271359
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number97377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: